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CDI is the short term for Clinical Documentation Integrity. CDI involves analyzing a patient’s health record documentation to ensure it is captured accurately in terms (diagnoses) by the physician to ensure a factual patient story. Within healthcare, terms stated by the physician are translated into codes that are used for reimbursement to providers, data collection, and quality measurements to say the least. CDI professionals work closely with physicians, medical coders, and other departments to ensure documentation represents the care and resources utilized during a patient visit.
I was fortunate in my career to attend the Medical University of SC which allowed me early exposure to clinical professionals. I was fortunate to take coursework with many. As a health information professional this gave me an edge as I also saw the chart from a coding viewpoint and CDI viewpoint. In 2000, I was charged with creating a CDI department and working with software that ensured compliance by looking for diagnoses that may have been under and over-coded. This gave me the opportunity to help build a program from scratch with coders and nursing staff. This helped me understand the importance of software and data analysis in this process early on. I went on to participate in CDI programs at academic institutions, small, medium, and large facilities. I also developed successful outpatient CDI programs for clinics.
The CDI reviews all components of the record to ensure diagnoses are stated and captured accurately. This includes reviewing the documentation of the physician to support the coding but also clinical documentation such as labs, radiology, and pharmacy to formulate questions to the physician called queries. Queries assist the physician in accurately telling the patient story and reflects the resources utilized in caring for the patient. CDI departments utilize software to help track patient reviews, develop queries, and analyze data. CDI's work with other departments as needed to complete this process. CDI departments usually consist of reviewers which are nurses and/or coders, leads, supervisors, and managers or directors. Many facilities only use nurse for the CDI function but many coders have the expertise and background.